Short-term psychodynamic psychotherapy: an asset in medical education

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Mohamad Matout is a Psychiatry Resident (R1) at McGill University

The debate regarding what should future doctors be learning during medical school is sensitive and convoluted. During the four years in which students learn basic sciences and acquire basic clinical knowledge, due to lack of time, little is taught with regards to major topics such as nutrition1, lifestyle changes, oral health2 and basic computer literacy3. One could argue that psychology is another field in which future physicians lack structured education. Our curriculum is usually centred around understanding the biology of pathophysiology and, when possible, the neurobiology of psychopathologies. While we may be introduced to the area of psychology and an understanding of pathologic defense mechanisms, the world of psychotherapy remains mysterious to medical students and physicians in general.

In my personal opinion, having some insight into psychological principles is crucial. The era during which mind and body were perceived as two separate entities has ended. If we are to move towards personalized medicine, one not only needs to understand how genetics, immunology and targeted pharmacotherapy apply to medicine — but also to understand the complex link existing between the psyche and the soma4. Fortunately, medical electives, when available, offer medical students the opportunity to supplement their medical education within areas of interest such as this.

Passionate about psychiatry and mental health, I was fortunate enough to be exposed to the art and science of psychodynamic psychotherapy through an interesting elective clinical rotation supervised by Dr. Said, a psychiatrist at the Allan Memorial Institute within McGill University Hospital Center. This is a course I believe would benefit any medical student, regardless of their desired speciality, as it would provide them with refined interpersonal skills for their future practice. It was an experience heavy in learning of new concepts. I had the opportunity to gain knowledge regarding the psychopathology of personality disorders and the underlying dynamic forces, as well as interview techniques. Not only did this rotation confirm my deep-seated interest in psychiatry, it also shaped the future physician I aim to be.

When one hears the term psychotherapy, one may envision a sympathizing professional listening to a patient vent. However, psychotherapy is much more complex than that. In actuality, it could be much more aggressive, emotionally invasive, and scientifically challenging. A simplistic definition of clinical science involves the identification of a repetitive pattern. Dr. Said found pleasure in teaching such patterns to his students through videotaped therapy sessions. In fact, he would “dissect” the phases governing psychodynamic psychotherapy and would remind students to pay attention to the processes rather than to the content. Processes, while laborious, are identifiable and, when applied appropriately, lead to results. In psychodynamics, where the goal is to access the patient’s unconscious, there is a dynamic sequence which consists of a number of phases: inquiry, pressure, challenge, transference resistance, partial or major dominance of the unconscious therapeutic alliance against the resistance, analysis of the transference, and dynamic exploration into the unconscious. One could argue that the evidence regarding the efficacy of short-term psychodynamic psychotherapy is limited and often non-conclusive. However, it is important to note that the extension of the evidence-based movement to psychotherapy is relatively new. I remain optimistic that with future trials, evidence will be more conclusive.

What Dr. Said teaches medical students and residents goes beyond the techniques of psychotherapy. His goal is not to influence all of us to become psychotherapists, but to encourage us to be careful when making psychiatric diagnoses. He requires us to understand in depth the “anatomy of psychopathologies,” which can’t be taught through a set of criteria; he emphasizes the importance of understanding the dynamics behind a patient’s presentation and how different factors interact with one another. He teaches us to be comfortable in differentiating neurosis (i.e., near-psychosis) from psychosis. This rotation allowed me to become more vigilant with regards to overdiagnosis in psychiatry.

This elective did affect me personally, and some days were more difficult than others. There were days where I returned home very exhausted, sad, calm, or mad. Other days, I would wake up feeling groggy, tired, or very anxious and I could not understand why. These were all part of the emotions that psychotherapists experience as a result of being invested in therapeutic relationships with their patients. When I started my elective, Dr. Said told me, “This rotation is usually difficult on residents as they must face their own ‘hell’ – which is their unconscious.” Over the course of the elective, I saw a change in me and my ability to tolerate anxiety. I had to go through a lot of thinking and introspection. I was able to discover myself through others and understand myself a lot better.

Although this elective was short and lasted only one month, I believe I gained a lot. I would encourage medical schools to expose their students to psychodynamic psychotherapy and its governing concepts early on during their training, as I believe it is an asset even for general practitioners. Psychiatrists are not the only ones diagnosing and treating mental disorders; primary care physician share that responsibility. As our society becomes more cognizant of the importance of mental health and reaching out, it would be a disservice from the medical community to pose wrong diagnoses because of our lack of understanding of psychiatric illnesses. In a field where clinical presentation is usually complex and where there are still no biological diagnostic markers, we must use every reasonable tool at our disposal to help a vulnerable patient population.